KABUL, Afghanistan — Once a river flowed under the low Pul-i-Sokhta bridge here, but now the thin stream is clotted with garbage, the banks are piled with refuse and crowds of heroin and opium addicts huddle in the shadows, some hanging like moths near the bridge’s supports, then slumping in the haze of narcotic smoke.
When outsiders venture in, dozens of the addicts — there are 200 or 300 here on any given day — drift over to see the newcomers. Most of the visitors are health care workers trying to persuade the addicts to visit their clinic for a shower and a medical screening.
“Are you taking names for treatment?” one man asks, his soiled salwar kameez hanging loosely around his thin body. “Put me down, my name is Zainullah.”
This is another of Afghanistan’s afflictions: a growing drug addiction problem and all the ills that come with that, not least H.I.V., the virus that causes AIDS, which can be transmitted when addicts share needles. There were about 900,000 drug users in Afghanistan in 2010, according to the United Nations Office on Drugs and Crime, a marked increase from previous years.
That means about 7 percent of the adult population of 14 million is using narcotics.
A vast majority take opium-based drugs, which are extraordinarily pure here and very cheap — about $3.50 for enough to get high, addicts say.
Afghanistan is the world’s leading producer of opium poppy, and the opium produced and sold here and its derivatives, including heroin, are among the most potent on earth. About 150,000 of those using opium-based drugs are injecting heroin, according to the World Health Organization.
A measure of the problem is that surveys show that 12 to 41 percent of police recruits test positive for some form of narcotic — most are hashish smokers — according to a recent report by the Government Accountability Office. Another indicator of the problem is a recent report by the Ministry of Public Health in partnership with Johns Hopkins University that found H.I.V. present in about 7 percent of drug users, double the figure just three years ago, said Dr. Fahim Paigham, who until recently directed the Ministry of Public Health’s AIDS control program.
Unlike the situation in many countries, where H.I.V. is transmitted primarily through sexual contact, in Afghanistan the primary transmission is through shared needles.
The Pul-i-Sokhta bridge — the name means “burned bridge” — and another bridge nearby are the most recent refuges for many of Kabul’s heroin and opium addicts who used to gather in the ruins of the Russian cultural center on the east side of the city. They were forced out in late 2010; although some remained in the neighborhood, many came to the bridges.
Some come here every day to buy and use narcotics, crouching in the dark corners to shoot up or gathering in small groups to heat the opium powder until it melts into a black liquid and gives off smoke to inhale.
The ground under the bridge is thick with discarded syringes. Six mornings a week a team of former addicts, nurses and a couple of social workers from the French group Médecins du Monde (Doctors of the World), a nonprofit health care organization, forge ahead into this particular circle of hell, with large plastic disposal jugs in one hand and long-handled pincers in the other to pluck needles from the garbage. It is not uncommon to pick up 160 or 170 needles in a morning. They hand out fresh needles and alcohol swabs, and the nurses treats the addicts’ seeping wounds where they have injected themselves too many times.
Not all the addicts are sure they can tolerate treatment, and some are so high they often make little sense. “I am the Bobby Devil of this town,” said a tall, bony young man in aviator glasses, cargo pants and a plaid cotton shirt, who was sprawled next to a small group smoking heroin, but had propped himself up on his elbows to talk. Bobby Devil is the stage name of an Indian actor well known here for his action movies.
“I’ve been using for four years,” he added. “Last night I went home with money and fresh fruit, and my wife and children told me to go away. They said, ‘You are a drug addict, you are a dog.’
Could he quit? “Well, I can’t decide; both my wife and the drug are strong,” he said and lay back down.
Many of the addicts say they want to stop using, but treatment options are woefully few. The government, through some Afghan nonprofit groups, runs several detoxification centers and is building seven more, but the facilities offer almost no post-detoxification support and have a 92 percent relapse rate, according to the Ministry of Counternarcotics, which is involved in running them. The most efficacious treatment — opiate substitution therapy — has been all but blocked by the ministry despite pleas from the Ministry of Public Health, whose doctors are worried about the rising incidence of H.I.V.
“The results from opiate substitutes like methadone are very positive,” Dr. Paigham said.
“If you stop using heroin, you stop using the needles, and if you stop using the needles there is much less risk of spreading H.I.V.”
Methadone is typically given in syrup form here. However, officials at the Ministry of Counternarcotics are leery of it, perhaps because they have the most experience with detoxification, but also, they say, because the opiate substitutes do not cure addiction.
“It is the view in Afghanistan it is just substituting one addiction for another,” said Mohammed Ibrahim, the deputy minister of counternarcotics.
The ministry undermined the country’s sole opiate substitution effort, a pilot program run by Médecins du Monde that administers methadone to 70 addicts. The program has been strongly endorsed by the World Health Organization as well as by participants, and it has a waiting list. However, the ministry twice blocked the import of the methadone, making it all but impossible for the heavily addicted participants to stick with the program.
For now the pilot program is running, but it has not been permitted to expand.
This year the number of drug addicts is expected to rise. Many Afghans start using narcotics when they seek work in Iran, which has one of the worst drug problems in the region. Increasingly, Iran is expelling addicted Afghans, shipping them back across the border. A few Afghan addicts say they were trying to quit while in Iran, which has a comprehensive system of methadone clinics that provide the drug, but most cannot imagine a way out.
“I started using in Iran from depression and sadness,” said Zainullah, 19, a
Hazara man from Ghazni Province. “I was alone. There was no one in Iran from my family. I went there to find work, and I started smoking heroin.”
He returned to his farming village and his nine siblings six months ago, but a month later came to Kabul.
“Nobody likes a drug addict, so my family sent me here to quit,” he said, speaking softly. “Instead, here I am under the bridge, and I have increased my dose since I came.
“If you could help me, please,” he said, raising his thin arms as if beseeching the aid workers. “I don’t know how to stop.”
ALISSA J. RUBIN
The New York Times 27th Aug 2011
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